ICR Exemplar: Traumatic brain Injury

What is a traumatic brain injury?

an injury which displaces the brain within the skull, causing an interruption to brain functioning

what is the scope of TBI?

closed head injury vs. penetrating trauma

Many manifestation of TBI are?

behavioral

what are coup-contrecoup injuries?

brain decelerates against one side of the skull and then reverberates to the other

what to keep in mind when children have a TBI?

• growth, social, and developmental vulnerabilities

• abusive trauma

• vehicular accidents

• sport injury

what to keep in mind when a pregnant person has a TBI?

intrapersonal violence

what to keep in mind when older adults have a TBI?

• mobility-related vulnerabilities

• medications

• ground-level falls

what are some primary injuries that can be caused by TBI?

• concussion

• hematoma (limited bleed)

• hemorrhage

• skull or facial fracture (may hit blood vessels or spill CSF)

• Penetration

• initial space-occupying lesion

what are some secondary injuries that can be caused by TBI?

• inflammatory cascade

• Cerebral edema

• space-occupying lesion grows

• herniation (bleeding or spinal cord is going down)

what are the types of hemorrhages?

• epidural hematoma (worse one, bleeds a lot)

• subdural hematoma

• subarachnoid hemorrhage

• intracerebral hemorrhage (penetrating)

what are some things to consider for a TBI?

• airway

• spinal cord injuries

What are assessments for TBI?

• Glasgow Coma Scale

• Levels of consciousness

• Pupil Assessment (PERRLA)

• Alert and Oriented assessment

what to assess for a mild TBI: Concussion?

• mechanism of injury

• immediate post-injury assessment

  • LOC/GCS

  • confusion

  • headache

  • memory loss

  • impaired balance

  • visual disturbance

• associated spinal injury risk

• Microscopic brain changes may not be visible on imaging

what are some interventions for a mild TBI: concussion?

• protect from further harm

  • remove from activity

  • low-stimulation environment

• anticipate invisible brain injury

• ongoing assessment at home, possible in person neuro checks

• No NSAIDS: can cause bleeding to increase

• Caution with opioids: can sedate them 

When is it safe to return to activities with a mild TBI: concussion?

• recommendations vary, individualized

• recovery can take days to months

What to assess for a severe TBI: motor vehicle accident (MVA)

• ABCD, AVPU, and GCS assessment at the accident scene

• spine, airway, and hemorrhage stabilization

• mechanism of injury

• imaging (MRI for bleed, CT for Fracture)

• intracranial monitoring

  • CPP = MAP - ICP

• mental status and LOC

• Pupillary assessment 

• vital signs →Cushing’s triad

• pain, skin (look for raccoon eyes), respiratory, etc

what interventions are needed for a severe TBI: motor vehicle accident (MVA)

• protect from further harm

  • safety

  • ultra low stimulation environment

• heavy sedation (look at pupils)

• intubation/ventilation

• invasive ICP and CPP monitoring (bolts)

  • IICP can indicate overstimulation

  • Pain can increase ICP

• clustering of care (have a plan)

• Seizure prophylaxis

• heavy sedation or induced coma (to lower ICP)

• Presumptive pain suppression (vital signs may go up)

• ICP can indicate overstimulation (under stimulate the patient)

• Long term planning with family (much later)

If we want to increase perfusion to the brain (CPP)

we have two ways we can intervene which are increase MAP or decrease ICP

How do we increase MAP?

• vasopressor drugs cause vasoconstriction and therefore increase BP

• Ex. epinephrine

how do we decrease ICP?

• hyperventilation (emergency only): causes vasoconstriction r/t hypocapnia (decrease CO2)

• Upright positioning (gravity!)

• sedation/induced coma: brain rest and energy conservation

• seizure prophylaxis

• osmotic diuresis: mannitol

• external fluid drain

• skill flap removal

How is osmotic diuresis: Mannitol given?

IV

How does osmotic diuresis: mannitol work?

• draws water from brain tissue into brain capillaries thus reducing cerebral edema and shrinking swollen brain tissue

• blood volume increases initially, then diuresis

What is contraindicated for osmosis diuresis: Mannitol?

• if the blood-brain barrier is disrupted (ex. if hemorrhage has not stopped)

• mannitol brings water inside the brain, leading to the opposite effect (IICP)

what is crucial for osmosis diuresis: mannitol/

tight interdisciplinary collaboration and careful monitoring

what should you be cautious about with osmosis diuresis: mannitol? 

when fluid balance is already a concern (heart failure, severe dehydration, shock, and kidney impairment)

What is the medication for TBI?

ICP-reducing agents

What is the prototype drug for ICP-reducing agents?

mannitol (osmitrol)

what is the mechanism of action for mannitol?

• draw water and plasma into the intravascular space

• thereby shifting excess fluid out of the brain

what are primary symptoms for mannitol?

decreased

• extracellular fluid

• intracranial pressure

Increased

• increased intravascular volume

• urine output (diuresis)

what are the adverse outcomes of mannitol?

• Pulmonary edema from the rapid shifts of fluid

• hypotension and dizziness

• electrolyte imbalances

• dehydration and fatigue

what to monitor for pulmonary edema?

• SOB

• crackles in lungs

• low SpO2

what is the response for pulmonary edema?

• hold and notify provider

• supplemental O2

• RRT if needed

what to monitor for hypotension and dizziness?

• low BP

• high HR

• report dizziness 

what is the response to hypotension and dizziness?

• hold and notify provider

• ensure safety

• prevent falls

what to monitor for electrolyte imbalances?

• electrolyte levels

• sodium

• potassium

what is the response for electrolyte imbalance

hold and notify provider

what to monitor for dehydration and fatigue?

fluid balance (intake and output)

what is the response for dehydration and fatigue?

• educate on need to diuresis

• avoid over-hydration which will increase ICP

what to remember about other pharmacology for severe TBI?

• sedatives for brain rest

• opioids for pain

• anti-seizure medication

• oxygen

• antipyretic (acetaminophen) to reduce fever